Form Phmsa F 7000 1 – Fill Out and Use This PDF

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NOTICE: This report is required by 49 CFR Part 195. Failure to report can result in a civil penalty not to exceed $25,000 for each violation	Form Approved
for each day that such violation persists except that the maximum civil penalty shall not exceed $500,000 as provided in 49 USC 60122	OMB No. 2137-0047

U.S. Department of Transportation

Pipeline and Hazardous Materials

Safety Administration

ACCIDENT REPORT – HAZARDOUS LIQUID

PIPELINE SYSTEMS

Report Date

No.

(DOT Use Only)

INSTRUCTIONS

Important: Please read the separate instructions for completing this form before you begin. They clarify the information requested and provide specific examples. If you do not have a copy of the instructions, you can obtain one from the Office Of Pipeline Safety Web Page at http://ops.dot.gov.

PART A – GENERAL REPORT INFORMATION

Check: Original Report Supplemental Report Final Report

1. a.	Operator's OPS 5-digit Identification Number (if known) /	/	/	/	/ /
b.	If Operator does not own the pipeline, enter Owner’s OPS 5-digit Identification Number (if known) /					/	/	/	/ /

c. Name of Operator ______________________________________________________________________________________

d. Operator street address _______________________________________________________________________________

e.Operator address ______________________________________________________________________________________

City, County, State and Zip Code

IMPORTANT: IF THE SPILL IS SMALL, THAT IS, THE AMOUNT IS AT LEAST 5 GALLONS BUT IS LESS THAN 5 BARRELS, COMPLETE THIS PAGE ONLY, UNLESS THE SPILL IS TO WATER AS DESCRIBED IN 49 CFR §195.52(A)(4) OR IS OTHERWISE REPORTABLE UNDER §195.50 AS REVISED IN CY 2001.

2. Time and date of the accident
/ / / / /	/ / /	/ / /	/ / /
hr.	month	day	year

3. Location of accident

(If offshore, do not complete a through d. See Part C.1)

a. Latitude: _____ Longitude: __________

(if not available, see instructions for how to provide specific location)

b._________________________________________________

City, and County or Parish

c._________________________________________________

State and Zip Code

d.	Mile post/valve station	or survey station no.
	(whichever gives more accurate location)
	_________________________________
4. Telephone report
/	/ / / / / /	/ / /	/ / /	/ / /
NRC Report Number		month	day	year

5.Losses (Estimated)

Public/Community Losses reimbursed by operator:

Public/private property damage	$_______________
Cost of emergency response phase	$_______________
Cost of environmental remediation	$_______________
Other Costs	$_______________

(describe) _____________________________________

Operator Losses:
Value of product lost	$_______________
Value of operator property damage	$_______________
Other Costs	$_______________

(describe) _____________________________________

Total Costs

$_______________

6. Commodity Spilled	Yes	No
(If Yes, complete Parts a through c where applicable)

a. Name of commodity spilled ___________________________

b. Classification of commodity spilled:

HVLs /other flammable or toxic fluid which is a gas at ambient conditions

CO2 or other non-flammable, non-toxic fluid which is a gas at ambient conditions Gasoline, diesel, fuel oil or other petroleum product which is a liquid at ambient conditions Crude oil

c. Estimated amount of commodity involved :

Barrels

Gallons (check only if spill is less than one barrel)

Amounts:

Spilled : ____________

Recovered: ____________

CAUSES FOR SMALL SPILLS ONLY (5 gallons to under 5 barrels) :

Corrosion	Natural Forces	Excavation Damage
Material and/or Weld Failures		Equipment

(For large spills [5 barrels or greater] see Part H)

Other Outside Force Damage

Incorrect Operation

Other

PART B – PREPARER AND AUTHORIZED SIGNATURE

(type or print) Preparer's Name and Title			Area Code and Telephone Number

Preparer's E-mail Address			Area Code and Facsimile Number

Authorized Signature	(type or print) Name and Title	Date	Area Code and Telephone Number
Form PHMSA F 7000-1 ( 01-2001 )			Page 1 of 4

Reproduction of this form is permitted

PART C – ORIGIN OF THE ACCIDENT (Check all that apply)

Additional location information

Offshore:

Yes

No (complete d if offshore)

a. Line segment name or ID

_______________________

d. Area ___________________ Block # ______________

b. Accident on Federal land other than Outer Continental

Shelf

Yes

State /

/ /

Outer Continental Shelf

c. Is pipeline interstate?

Yes

Location of system involved (check all that apply)

a. Type of leak or rupture

Operator’s Property

Leak:

Pinhole

Connection Failure (complete sec. H5)

Pipeline Right of Way

Puncture, diameter (inches)

_________

High Consequence Area (HCA)?

Rupture:

Circumferential – Separation

Describe HCA____________________________________

3. Part of system involved in accident

Longitudinal – Tear/Crack, length (inches) ___________

Above Ground Storage Tank

Propagation Length, total, both sides (feet)

_________

Cavern or other below ground storage facility

N/A

Pump/meter station; terminal/tank farm piping and

Other _______________________________

equipment, including sumps

b.Type of block valve used for isolation of immediate section:

Other Specify: _________________________________

Upstream:

Manual

Automatic

Remote Control

Check Valve

Onshore pipeline, including valve sites

Downstream:

Manual

Automatic

Remote Control

Offshore pipeline, including platforms

Check Valve

If failure occurred on Pipeline, complete items a - g:

c. Length of segment isolated

_______ ft

4. Failure occurred on

d. Distance between valves

_______ ft

Body of Pipe

Pipe Seam

Scraper Trap

e. Is segment configured for internal inspection tools? Yes

Pump

Sump

Joint

f. Had there been an in-line inspection device run at the point of

Component

Valve

Metering Facility

failure?

Yes

Don’t Know

Repair Sleeve

Welded Fitting

Bolted Fitting

Not Possible due to physical constraints in the system

g. If Yes, type of device run (check all that apply)

Girth Weld

High Resolution Magnetic Flux tool

Year run: ______

Other (specify)

Year the component that failed was installed: /

Low Resolution Magnetic Flux tool

Year run: ______

UT tool

Year run: ______

5. Maximum operating pressure (MOP)

Geometry tool

Year run: ______

a. Estimated pressure at point and time of accident:

____

PSIG

Caliper tool

Year run: ______

b. MOP at time of accident:

Crack tool

Year run: ______

___________PSIG

Hard Spot tool

Year run: ______

c. Did an overpressurization occur relating to the accident?

Other tool

Year run: ______

Yes

PART D – MATERIAL SPECIFICATION

PART E – ENVIRONMENT

Nominal pipe size (NPS)

in.

1. Area of accident

In open ditch

Wall thickness

in.

Under pavement

Above ground

Specification

SMYS /

Underground

Under water

Inside/under building

Other

____________

4.Seam type

5.Valve type

2. Depth of cover:

inches

6. Manufactured by

in year /

/ / / /

PART F – CONSEQUENCES

1. Consequences (check and complete all that apply)

Fatalities

Injuries

c. Product ignited

Yes

d. Explosion

Yes

Number of operator employees:

_______

Evacuation (general public only)

/ /

/ people

Contractor employees working for operator:

_______

Reason for Evacuation:

General public:

_______

Precautionary by company

Totals:

_______

Evacuation required or initiated by public official

b. Was pipeline/segment shutdown due to leak?

Yes

f. Elapsed time until area was made safe:

If Yes, how long? ______ days ______ hours _____ minutes

/ / /

hr.

/ /

min.

2. Environmental Impact

a. Wildlife Impact:

Fish/aquatic

Yes

e. Water Contamination:

Yes

(If Yes, provide the following)

Birds

Yes

Amount in water _________ barrels

Terrestrial

Yes

Ocean/Seawater

Yes

b. Soil Contamination

Yes

Surface

Yes

If Yes, estimated number of cubic yards: _________

Groundwater

Yes

c. Long term impact assessment performed:

Yes

Drinking water

Yes (If Yes, check below.)

d. Anticipated remediation

Yes

Private well

Public water intake

If Yes, check all that apply:

Surface water

Groundwater

Soil

Vegetation

Wildlife

Form PHMSA F 7000-1 ( 01-2001 )

Page 2 of 4

Reproduction of this form is permitted

PART G – LEAK DETECTION INFORMATION

1.Computer based leak detection capability in place?

2.Was the release initially detected by? (check one):

3. Estimated leak duration days ____ hours ____

Yes No

CPM/SCADA-based system with leak detection

Static shut-in test or other pressure or leak test

Local operating personnel, procedures or equipment

Remote operating personnel, including controllers

Air patrol or ground surveillance
A third party	Other (specify) _________________

Important: There are 25 numbered causes in this Part H. Check the box corresponding to the

PART H – APPARENT CAUSE

primary cause of the accident. Check one circle in each of the supplemental categories corresponding

to the cause you indicate. See the instructions for guidance.

H1 – CORROSION

a. Pipe Coating

b. Visual Examination

c. Cause of Corrosion

External Corrosion

Bare

Localized Pitting

Galvanic

Atmospheric

Coated

General Corrosion

Stray Current

Microbiological

Other ____________________

Cathodic Protection Disrupted

Internal Corrosion

Stress Corrosion Cracking

Selective Seam Corrosion

Other ____________________

(Complete items a – e where

applicable.)

d. Was corroded part of pipeline considered to be under cathodic protection prior to discovering accident?

Yes, Year Protection Started: / /

e. Was pipe previously damaged in the area of corrosion?

Yes ⇒ Estimated time prior to accident:

/ years / / / months

Unknown

H2 – NATURAL FORCES

Earth Movement

⇒

Earthquake

Subsidence

Landslide

Other

4.Lightning

5.	Heavy Rains/Floods	⇒	Washouts	Flotation	Mudslide	Scouring	Other
6.	Temperature	⇒	Thermal stress	Frost heave	Frozen components		Other

7.High Winds

H3 – EXCAVATION DAMAGE

8.Operator Excavation Damage (including their contractors/Not Third Party)

9.Third Party (complete a-f) a. Excavator group

General Public

Government

Excavator other than Operator/subcontractor

b. Type:

Road Work

Pipeline

Water

Electric

Sewer

Phone/Cable

Landowner-not farming related

Farming

Railroad

Other liquid or gas transmission pipeline operator or their contractor

Nautical Operations

Other

________

c. Excavation was:

Open Trench

Sub-strata (boring, directional drilling, etc…)

d. Excavation was an ongoing activity (Month or longer)

Yes

If Yes, Date of last contact /___/___/___/

e. Did operator get prior notification of excavation activity?

Yes; Date received: /

mo. /

/ day /

/___/___/ yr.

Notification received from:

One Call System

Excavator

Contractor

Landowner

f. Was pipeline marked as result of location request for excavation?

Yes

(If Yes, check applicable items i - iv)

Temporary markings:

Flags

Stakes

Paint

ii.

Permanent markings:

iii.

Marks were (check one) :

Accurate

Not Accurate

iv. Were marks made within required time?

Yes

H4 – OTHER OUTSIDE FORCE DAMAGE

10.

Fire/Explosion as primary cause of failure ⇒ Fire/Explosion cause:

Man made

Natural

11.Car, truck or other vehicle not relating to excavation activity damaging pipe

12.Rupture of Previously Damaged Pipe

13.Vandalism

Form PHMSA F 7000-1 ( 01-2001 )

Page 3 of 4

Reproduction of this form is permitted

Form PHMSA F 7000-1 (01-2001 )

H8 – OTHER

H7 – INCORRECT OPERATION

H5 – MATERIAL AND/OR WELD FAILURES

Material
14.	Body of Pipe	⇒	Dent	Gouge	Bend	Arc Burn	Other
15.	Component	⇒	Valve	Fitting	Vessel	Extruded Outlet	Other
16.	Joint	⇒	Gasket	O-Ring	Threads		Other
Weld
17.	Butt	⇒	Pipe	Fabrication			Other
18.	Fillet	⇒	Branch	Hot Tap	Fitting	Repair Sleeve	Other
19.	Pipe Seam	⇒	LF ERW	DSAW	Seamless	Flash Weld
			HF ERW	SAW	Spiral		Other

Complete a-g if you indicate any cause in part H5.

a. Type of failure:

Construction Defect ⇒ Poor Workmanship Procedure not followed Poor Construction Procedures Material Defect

Was failure due to pipe damage sustained in transportation to the construction or fabrication site?

Yes

Was part which leaked pressure tested before accident occurred?

Yes, complete d-g

Date of test:

/ yr.

/ mo. /

day

Test medium:

Water

Inert Gas

Other

Time held at test pressure:

hr.

g. Estimated test pressure at point of accident:

PSIG

H6 – EQUIPMENT

20.

Malfunction of Control/Relief Equipment

⇒

Control valve

Instrumentation

SCADA

Communications

Block valve

Relief valve

Power failure

Other

21.

Threads Stripped, Broken Pipe Coupling

⇒

Nipples

Valve Threads

Dresser Couplings

Other

22.

Seal Failure

⇒

Gasket

O-Ring

Seal/Pump Packing

Other

23.	Incorrect Operation
a. Type:		Inadequate Procedures		Inadequate Safety Practices	Failure to Follow Procedures
		Other	_______________________________________

b. Number of employees involved who failed a post-accident test: drug test: /		/	/	/	alcohol test /___/___/___/

Page 4 of 4

Reproduction of this form is permitted

Question	Answer
Form Name	Form Phmsa F 7000 1
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	O-Ring, h7 form, dot hs 7 fillable, H5

Miscellaneous, describe:

Investigation Complete

Still Under Investigation (submit a supplemental report when investigation is complete)

PART I – NARRATIVE DESCRIPTION OF FACTORS CONTRIBUTING TO THE EVENT

(Attach additional sheets as necessary)